Ventilator Associated Pneumonia Overview

1. Ventilator Associated PneumoniaOverview • Ventilator-associated pneumonia (VAP) occurs in 10-20% of intubated patients. • It is one of the most important nosocomial infections encountered in the intensive care unit (ICU). • VAP is an airway infection that has developed >48 hours after the intubation. • Mortality rates range from 24-50%, depending on individual comorbidities and the pathogen involved. • VAP increases ICU length of stay to 6.1 days & hospital length of stay to 10.5 days. • Each VAP is adds an estimated $40,000 to patient care costs.

2. Ventilator Associated PneumoniaPathophysiology • After a period of hospitalization, patients’ oral cavity becomes colonized with microorganisms. • Impairment of host defenses predispose patients to infection with colonizing organisms. • Organisms enter upper respiratory system around the cuff of the endotracheal tube. • Infection of the lower respiratory track results from organism migration.

3. Ventilator Bundle Ventilator Bundle Defined: a group of interventions related to ventilator care that, when all interventions are applied simultaneously, there is enhanced reduction in incidence of VAP than when each intervention is implemented separately (Institution of health care improvement, 2011). Ventilator Bundle Component Elements: • Head of bed elevation at least 30 degrees. • Daily sedation interruption with readiness to wean assessment. • Peptic ulcer disease prophylaxis. • Deep vein thrombosis prophylaxis. • Thorough daily oral care with subglottic suctioning. 

4. Subglottic Suctioning • Removing secretions that have accumulated above the ETT is a significant strategy for VAP prevention. A meta-analysis found that ETTs with continuous or intermittent subglottic suction decreased the incidence of VAP in patients expected to be mechanically ventilated longer than 72 hr (Rewa & Muscedere, 2011). • Recent additional randomized controlled trials have confirmed that VAP incidence is decreased when continuous or intermittent subglottic suctioning is used.

5. TaperguardTM Subglottic Endotracheal Tube Connect in-line suction here • Found in Pyxis and on top of crash carts. • Prefer to use this ETT rather than traditional ETT. • Use in-line suction. • Connect an additional suction at low continuous suction (60-80 mm) to subglottic port. • If unable to connect two suctions, leave connected to subglottic port and switch to ETT when needing to ET suction. Subglottic port is suctioning secretions off the top of the ETT cuff. Connect second continuous suction here

6. Oral Care • Tooth brushing has been recommended as an important intervention in critically ill patients to remove the plaque biofilm that is a potential risk of infection. • Not brushing for four days causes bacteria to accumulate in sub-gingival crevices of the teeth, causing gingival inflammation and bleeding, and increase the risk for aspiration of the bacteria.

7. Studies Describing Oral Care for Prevention of VAP

8. Oral Care Kits in Pyxis Stock

9. Quick Review: Mouth Care For Intubated/ Unconscious Patients • Perform mouth care every 4 hours. • Brush teeth using suction toothbrush and accompanying anti-plaque solution q 12 hours. • Brush for approximately one to two minutes by exerting gentle pressure while moving in short horizontal or circular strokes. • Gently brush the surface of the tongue. • If brushing causes discomfort or bleeding uses suction swab side of toothbrush to clean the teeth and tongue. • Post brushing, utilize the oropharyngeal suction catheter from the oral care kit to remove the oropharyngeal secretion. • Apply mouth moisture inside mouth and on lips with accompanying swab q 4 hours. • Utilize accompanying Yankauer suction as needed to remove oral secretions throughout the shift. See appendix C in the policy of management of adult patient requiring mechanical ventilation

10. Recommendations • Oral care should be provided every four hours, but that does not mean oral brushing only. It also means oral rinsing 3 times a day with suctioning, and providing moisture to the lips and oral mucosa every six hours. • When a patient is admitted to a critical care unit, an oral history should be collected because prexisting gingivitis and periodontitis increase the risk of bacteremia. • Nurses should perform baseline and ongoing oral examinations to evaluate the oral health of the patients. • Use closed suction method to decrease the incidence of reintroducing bacteria into the airway. • Proper sterile endotracheal and subglottic suction techniques help reduce the migration of bacteria into the lower airway.

11. Selected References • Ames, N. J. (2011). Evidence to support tooth brushing in critically ill patients . Pulmonary Critical Care, 20 (3), 242-250. doi: 10.4037/ajcc2011120. • Lalla, R. V., Sonis, S. T., & Peterson, D. E. (2007). Management of oral mucositis in patients with cancer . Dent Clin North Am, 52(1). doi: 10.1016/j.cden.2007.10.002 • Young,P., Carroll, M., Farber, M,, et al. (2007). Implementing a ventilator bundle in a community hospital. The Joint Commission Journal on Quality and Patient Safety, 33(4),219-225. • Rewa,O. , Muscedere, J. (2011). Ventilator-Associated Pneumonia: Update on Etiology, Prevention, and Management. Curr Infect Dis Rep, 13, 287–295.

12. Selected References • Mori H, Hirasawa H, Oda S, Shiga H, Matsuda K, Nakamura M. Oral care reduces incidence of ventilator-associated pneumonia in ICU populations. Intensive Care Med. 2006; 32(2):230-236. • Munro CL, Grap MJ, Jones DJ, McClish DK, Sessler CN. Chlorhexidine, toothbrushing, and preventing ventilator associated pneumonia in critically ill adults. Am J CritCare. 2009; 18(5):428-437; quiz 438. • Sona CS, Zack JE, Schallom ME, et al, The impact of a simple, low cost oral care protocol on ventilator associated pneumonia rates in a surgical intensive care uint. Journal intensive care medicine. 2009; 24 (1):54-62